Getting to Know You
Share your contact, eligibility, health, and background details to begin the assessment.
Funding & Move-In
Was a case manager who recommended you involved?
*
Yes
No
Case manager name
First Name
Middle Name
Last Name
Case manager phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Case manager email
example@example.com
Case manager organization
Main income source
*
Please Select
VA
SSI
SSDI
Employment
Family support
Benefits
Other
Monthly income amount
*
Are you receiving funding assistance for move-in costs from an organization?
*
Yes
No
Desired move-in date
*
-
Month
-
Day
Year
Date
Can you pay the first month's rent on the day of move-in? Second month is prorated if move-in is after the 3rd.
*
Yes
No
Personal Information
Best phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth
*
-
Month
-
Day
Year
Date
Last 4 digits of national ID for background check
*
Height
Weight
Have you lived in a room and board or residential program before?
*
Yes
No
If yes, please be prepared to provide the contact information, address of your most recent home, reason for leaving, and any government assistance you receive.
Emergency contact full name
*
First Name
Middle Name
Last Name
Health & Wellness
Any physical health conditions
None
Diabetes
Asthma
Heart condition
Seizures
Mobility impairment
Chronic pain
Other
Any special needs or assistance needed for daily living
None
Mobility assistance
Medication management
Meal preparation
Personal care
Transportation assistance
Communication assistance
Other
Any mental health diagnoses
None
Bipolar disorder
Schizophrenia
Depression
Anxiety disorder
PTSD
Other
Medication adherence history and any recent gaps
Currently taking any medications
No medications
Prescription medications
Over-the-counter medications
Supplements
Other
Current medications and whether medication reminders are needed
Known allergies
Medical insurance and history of self-harm or suicide concerns
Background
Have you ever been arrested, charged, or convicted of a crime or felony?
*
Yes
No
If yes, provide details for each incident
Have you ever used any of the following substances?
*
Marijuana
Methamphetamine
Opioids
Opiates
Heroin
Fentanyl
Other controlled/street drug
None
Substance use details and current use
Rows
Explain if used
Last use
Currently use
Marijuana
Methamphetamine
Opioids
Opiates
Heroin
Fentanyl
Other controlled/street drug
Do you use alcohol?
*
No
Yes, occasionally
Yes, weekly
Yes, daily
Do you use tobacco?
*
No
Yes, occasionally
Yes, daily
Submit
Should be Empty: